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Friday, 9 May 2014

2014 - The role of the GP in the care of veterans with mental health problems

This article was authorized to be uploaded to my blog by

Dr. Anthony Frith

Fellow of the Royal College of General Practitioners

and

Ivan Hostens,

Adjudant-Major, Secretary Executive of

ICMM, Secretary of the Editorial Board.

Published at the International Review of the Armed Forces Medical Services, Vol 87/1-March 2014

Dr. Anthony Frith

Dr. Frith graduated as a doctor form Liverpool University in 1973 and worked as a general medical practitioner in the North West of England from 1977 until 2011. He has been a Fellow of the Royal College of General Practitioners since 2001, with whom he has collaborated on veteran’s mental health issues in primary care. He was the clinical lead in mental health for Halton and St Helens Primary Care Trust in England from 2005 to 2011. During this time, he worked with a local veterans association to improve awareness of veteran’s mental health issues within local primary care organisations, as well as completing a masters in mental health. He currently works as a GP in New Zealand, where he has continued to be involved in mental health issues and veterans problems, as well as concentrating on Maori health issues.

The role of GPs in the care of veteranswith mental health problems

Abstract

Background

Veterans with mental health problems are a challenging group of patients. Little research so far has been done into GP’s view of their role in their care.

Aim

To explore GPs’ perspectives on how general practice can contribute to the care of veterans with mental health problems

Design and study

A qualitative studyof the views of nine experienced GPs practicing in the north west ofEngland.

GPs themselves view veterans with mental health problems as deserving and needy groups who often have a complex mix of problems. Management within primary care is often frustrated by limitations to the care that veterans will accept, and by inadequate access to quality services to refer to.The GPs who wereinterviewed considered that, despite these limitations, they had a significant role to play by providing good quality holistic, patient-centred standard GP care and providing the benefits of family centred primary care. Mental health care by GPs provides opportunities to screen for mental health problems, initial management of acute mental illness, on-going support and risk assessment.

Conclusions

The care of veterans could be improved by using GPs involvement in commissioning.

GPs need more support in the organisation of information systems to identify veterans, and training in veterans’ issues.

GPs have holistic skills that can contribute to the care of veterans with mental health problems.

Introduction

Definition of a veteranVeterans include anyone who has served for at least one day in HM Armed Forces (Regular or Reserve), as well as Merchant Navy seafarers and fishermen who have served in a vessel which was operated to facilitate military operations by HM Armed Forces.1

The mental trauma of taking part in armed conflict has been documented for many decades, but only recently understood. For instance, it has been documented that 40% of soldiers in the Battle of the Somme suffered “shell-shock”,2 but effective management and treatment had to await defining and understanding of post-traumatic stress disorder. Much is now known about the immediate and long term effects of conflict on serving soldiers and veterans. Most of this research comes from the USA. Yet the UK has a sizeable veteran population, estimated to be 5 million3 and since 1945 has been involved in over 20 conflicts. The main drive in UK research has come from the King`s Centre for Mental Health.4The gaps in the research concern how mental health problems in veterans are affected by different settings when they leave the services. Historically, research has concentrated on services that specialize in veterans care.Little has been done looking at veterans care in the UK general practice setting, even though most general mental illness is currently managed in primary care.5 What role do UK GPs have in veterans’ care? Do they have the skills and knowledge needed?

Methods

This qualitative study looked at the views of experienced GPs using semi-structured, in-depth interviews with nine GPs in practice in the North West of England in 2012.

GPs were chosen on the basis of experience as GPs and a track record of clinical leadership.

The interviews were semi-structured and tape recorded to be later transcribed into written text. In addition, field notes were written during or shortly after the interviews, summaries of which were fed back to interviewees for comments. Further analysis of the data from the interviews used Interpretative phenomenological analysis

A constructivist model was taken in seeking to understand the perceptions and lived experiences of general practitioners dealing with veterans’ mental health problems.

Observations about the strengths of the GP, the opportunities for developing their role and how well equipped GPs are to take on the opportunities for care of veterans were set against a background of the issues veterans present to GPs, and the limitations and boundaries to GP care.*

Each successive interview was influenced by themes that emerged from the last interview.

Results

Nine GPs practicing in the North West of England were interviewed. One GP was female, nearly all had been in practice for at least 10 years (average = 19 years). Their experience varied from working as a GP trainer, Fellowship trainer, GP appraiser, to clinical and commissioning leads.

8 themes emerged from the interviews:

Background experience of veterans as patients within the practice.*

What was the experience of the GPs with veterans with mental health problems as patients?

What problems do veterans with mental health difficulties present to the individual GP?

What is the potential role for the competent GP in the care of veterans?

How should GPs process veterans’ mental health issues that arise during consultations?

How well equipped are GPs to deal with mental health problems in veterans?

What opportunities are there for GPs to be more involved in managing mental health problems in veterans?

What are the limitations to the role of GPs and where do the boundaries lie?

There was considerable variation in the experiences of the GP interviewees in terms of the number of veterans they had seen or were aware of in their practice (from hardly any to quite a few) although not in their observations about the nature of veterans’ problems or the interaction with the GP. This was surprising, given that they were all above average GPs, in leadership roles, presumably from well organised practices, although this observation could not statistically be extrapolated to suggest the same variation in the wider population of GPs, as this was a qualitative study with a statistically small, unmatched sample. The interviewees thought that this variation might be explained both by variations in GP quality, and by the fact that even the best practices have to balance the needs of veterans with the needs of other high risk groups competing for finite resources, including the resource of GP time and interest.

“From a vet’s point of view I think it varies quite a bit by practice ….

I’ve talked to other doctors who are not really interested, quite frankly …. I suspect vets get a different response from different surgeries”

What is very clear is that GPs view veterans as a needy, hard to reach group within their practice population. They are deserving of help, both because they are an at-risk group with above average levels of distress and problems, and also because GPs have a fundamental respect for their veteran status. That respect, in those GPs interviewed, was partly because of direct experience of caring for veterans, and also because of a sense that the community that GPs belonged to owes a lot to those who serve their country in war.“I assume they are tough individuals. Quite frankly, I enjoy talking to these people - they’re interesting, they have some interesting stories ………… But get it wrong first time – whatever you’ve said, done, organised – they will disappear - that’s what they’re like as people”“I do sympathise, I do understand as a member of society the role of veterans and the sacrifice that they’ve made”

Yet, evidently narrated by those interviewed, managing mental health problems in veterans presents significant challenges for the GP, and whilst this can sometimes be very rewarding, more often it is frustrating. That frustration, in the view of the GPs, was partly due to the complexity and severity of the problems, especially in the interplay between armed service experience, individual veteran personality, social, psychological and physical illness factors. Alcohol and substance misuse significantly worsened the chance of successful intervention within primary care and within specialist services, as did negative attitudes by veterans towards such interventions – most noticeable with attitudes towards psychological and alcohol interventions.

“With the cases that I’ve dealt with there has certainly been substance misuse, particularly alcohol has been a feature and that has been more complicated to manage”

On the fundamental question of what care GPs could and should provide, there was a wide range of ideas. A central theme to this was that core GP qualities of holistic care, good listening skills, empathy and a patient-centred, rather than disease-orientated, approach has much to offer for veterans. The GPs felt that patient trust and respect were generally high, and that they were a first point of contact for veterans and their families. Indeed,* the fact that families had easy access to the GP was often the only way problems in veterans came to light.

“[my role as a GP with veterans is] firstly to hear the story, what are they actually saying, try and help them understand what it is they are saying, being listened to and taken seriously – if you haven’t communicated that, you’ve lost it”There was a strong feeling that there was a considerable opportunity to use the highly effective IT systems within practices to identify veterans within the GP consultation so as to target appropriate care and screen for mental health problems. The difficulty highlighted was that this would need considerable organisation within practices and by outside agencies such as government, although none of the interviewees said this was unachievable.

“You’ve got to have it coded [being a veteran] … the most fundamental way of providing proactive health care is to have a system that identifies people at risk and doing something about it “Many of the GPs felt that they had a significant role once mental health problems had been identified - more than just signposting to more specialised services. Most felt that some initial management of developing mental health problems within primary care was possible, along with on-going support and risk assessment even when veterans had been referred. As there was a high default rate in those referred, and a feeling with some GPs that specialist services were not very good or accessible, the problems often returning to the GP anyway. An exception was post-traumatic stress disorder, which usually triggered early referral, as GPs felt they had limited skills in this area.

“There is a tendency to read this as ‘they’ve got special needs, you must refer them on, they’ve got a fast track service,’ which may be true, but I would rather give them a dose of ‘GP’ first. You feel patients appreciate that and especially veterans”

One important theme to emerge as the interviews progressed was that the role of GPs in the care of veterans was not confined to the consultation room. GPs have an important role as advocates for veterans, both for individual patients and collectively for all veterans in their practices. For some GPs, this meant writing letters on behalf of patients for housing or benefits. For others, it meant actively complaining where there was a perceived lack of access to, or poor quality of, specialist and psychological services. Often this was by direct contact with those services. Most of the interviewees acknowledged the growing role of GPs in commissioning health care and saw that as an opportunity to commission for improved access to quality services for veterans.

“The issue of hard to reach and vulnerable people is way up the agenda [in commissioning]`”

Although the interviews highlighted opportunities for GPs to develop the role they and their fellow GPs could play in the care of veterans with mental health problems, there were important limitations noted, including lack of time, lack of training of GPs in veterans issues, patchy GP skills in dealing with mental health problems generally and lack of professional peer support. Other limiting factors included lack of information about which patients in the practices were veterans, and areluctance, by a significant proportion of veterans, to accept the help GPs could give.

Although some GPs were conscious of fixing boundaries to their role so that they did not have to step outside their level of competence, many felt that one of the strengths of general practice was the great flexibility in the boundaries of GP care. How far the GPs viewed their role varied considerably from GP to GP, but in the end it was often the veterans themselves who defined the boundaries.

“I am here to be used when I am useful. There’s one particular chap who sees me very intermittently.... who will appear from time to time, we will have a moderately long discussion about where he’s up to, and then he’ll disappear again. In no sense is he dependent on me, but I suspect that he finds me a moderately useful sounding board from time to time”

Discussion

The role of the UK National Health Service in the health care of veterans has been increasing since the end of World War 2.

Priority treatment for veterans whose illness was caused by their time in the services was introduced in 1953 and was extended in 2007.

Despite this, a survey in London as recently as 2008 showed that there were over a thousand homeless veterans on any night.6 The NHS Operating Frameworks from 2008 onwards placed specific emphasis on strategic health planning for veterans.7 The Royal College of GPs has produced an advice leaflet for GPs.8There are gaps in the research about how known mental health problems are affected by different settings that veterans find themselves in when they leave the armed services.

Historical and current research has concentrated on research done by services that specialize in veterans care, such as the United States Department of Veterans Affairs and the King’s Centre for Military Health Research in the United Kingdom.The purpose of this research was not to get a consensus about how GPs manage veterans with mental health problems, but rather to broaden the range of ideas about how primary care might contribute to veterans’ care. The research makes no comment about the quality of current services provided by GPs. This is the first qualitative study known to the author of the experiences and views of professionals working within primary care about veterans presenting with mental health problems, so it gives an insight into GPs attitudes towards veterans.It explores opportunities for GP care, against a background of the difficulties faced by GPs and the limitations and boundaries in their professional role as a key member of the primary care team.

This study demonstrates that GPs themselves view veterans with mental health problems as a deserving and needy group. Although sometimes satisfying to work with, veterans often have a complex mix of psychological, social and physical problems, and management within primary care is often frustrated by the care that veterans will accept and by inadequate access to high quality services. Alcohol problems play a big part in the mental health issues and significantly influences what can be done for veterans.

Never-the-less, the GPs interviewed felt that they had a significant role to play, not least by providing good quality, holistic, patient-centred care in a family orientated practices, with good primary care to families of veterans, in addition to early recognition of developing problems when family members reported issues that veterans themselves were reluctant to seek help for.

Those interviewed saw considerable opportunities for the future by improving systems to identify and highlight veterans, and by a developing advocacy role. Care of veterans in the future could be enormously improved by GPs’ involvement in commissioning, which at the very least could improve access to high quality specialised services.

Conclusions and recommendations

Those interviewed saw considerable opportunities for the future by improving systems to identify and highlight veterans, and by a developing advocacy role. Care of veterans in the future could be enormously improved by GPs involvement in commissioning, which at the very least could improve access to high quality specialised services when necessary.

GPs need more support in the organisation of information systems to identify veterans. They need appropriate training in managing mental health problems in general, and in veterans’ issues in particular.Their role in commissioning services for veterans with mental health problems needs highlighting, encouraging and supporting, as do other advocacy roles GPs have for their veteran patients.GPs have well recognised holistic skills, which are subject to regular scrutiny and benchmarking. To make the best use of opportunities to develop the role of the GP in the care of veterans with mental health problems, those current skills need recognising and highlighting.

Comparison with literature

Much is known about the mental health problems suffered by veterans. The experiences of the GPs in this study correlate with literature studies on veterans, for instance the difficulties veterans experience in family and partner relationships 9,10the reluctance of veterans to seek help,11, 12the negative impact of military culture,13 14 the influence of alcohol,15the mental health legacy from conflicts many years ago.16, 17, 18

Previous authors have stated that the key strengths of general practice lie in the doctor-patient relationship and holistic care skills,19within a setting that is cost-effective, based on local population priorities.20The GPs in our study demonstrated the clinical and interpersonal effectiveness of general practice that has been well documented by others.21They recognized the value of the ‘non-specific healing effect’ of their consultations, as described by previous authors.22

Literature about mental health problems in the community has been biased by specialist psychiatry. Gask argued that primary care mental health research is in its infancy, and more is needed to look at primary care across the full spectrum of mental health problems.23 Our research adds the GP care of veterans to that spectrum.

Limitations of the study

This study looked at the viewpoint of GPs and fills a gap in the knowledge base about GP care of veterans. Future studies could combine the views of primary care professionals, especially GPs, with the views from outside the profession, including politicians, health care managers and veterans themselves. Studies that combined the views of GPs and family members caring for veterans with mental health problems would be particularly helpful.

This study was a qualitative study. Its strength is that it gathered the views of GPs in leadership roles, but a future quantitative study might be of additional use to health service planners.

The sample selection was carefully planned and in the end proved sufficient for the outcome, but alternative sample methods could have been used and might have been more effective. There was only one female interviewee. Although there was no attempt to look at the difference between male and female GP’s views, a higher proportion of female GPs might have expanded the range of ideas expressed.

How this study fits in

There is evidence from the literature that veterans have complex mental health problems that are not being fully met by current services. There is a lack of research about the views of GPs about the care of veterans. This study is the first qualitative study on GPs’ perception of their role and highlights how that could contribute to improving care for veterans.

Although this was a study of British GPs, it has relevance to primary care workers in all countries that have significant veterans’ mental health issues.

Villa, V. Harada, N. (2002). Health and functioning among four eras of U.S. veterans:
examining the impact of war cohort membership, socioeconomic status, mental
health and disease prevalence. Military
Medicine. September 2002, vol/is 167/9

O’Toole, B et al. (2010). The mental health
of partners of Australian Vietnam veterans three decades after the war and its
relation to veterans military service, combat and PTSD.Journal of Nervous & Mental Disease.Nov 2010, vol/is 198/11:
841-5

Lloyd, D.
(1994) Joint Working Party of the Welsh Council of the Royal College of General
Practitioners and the Welsh General Medical Services Committee (1994). Patient
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